By Dr James
Kimani, Senior Analyst (Population Council, Nairobi, Kenya)
Addressing
the postpartum needs of new mothers, including new mothers who are living with
HIV, and new mothers living in settings with a high HIV prevalence, is a
neglected area of care throughout sub-Saharan Africa and other resource-limited
settings. Few developing countries have mechanisms in place to ensure that
mothers and their newborns are assessed early and monitored during the initial
six-week postpartum period.
Some of the
challenges include lack of clearly defined standards, including the content and
timing of both postpartum and postnatal services, and a discontinuity of
services limiting linkages to other key postpartum services for new mothers,
including family planning and HIV care services for women living with HIV.
According
to the World Health Organization, over 60 per cent of maternal deaths occur
within the first 48 hours after childbirth [2], while newborn morbidity and
mortality, including postnatal transmission of HIV to infants, are more likely
to happen soon after birth [3, 4]. In high HIV prevalence settings,
there is also evidence that women living with HIV are at 1.5–2 times greater
risk of maternal mortality than women who are HIV-negative [5]. Providing adequate and effective
services to meet the needs of mothers and their infants during this postpartum
period can substantially reduce maternal and infant morbidity and mortality.
It is often
assumed that women who deliver in a facility will have received adequate care
prior to discharge and do not need further attention until the six-week
consultation. Women giving birth at home are least likely to receive any care,
especially within the first two days, when they are most susceptible to
postpartum hemorrhage and hypertensive disorders [6].
However, our
research has supported other studies that have found that regardless of where a
woman gives birth, she is unlikely to receive the comprehensive care she needs.
Two critical issues need further attention – the first, to promote family
planning and prevent future unintended pregnancies, and the second, to prevent vertical
transmission of HIV during the postpartum period.
To promote
family planning, research has shown that during the extended postpartum period
(12 months after birth), women may want to delay or avoid future pregnancies,
but do not have access to a modern contraceptive method. A review of data from
Demographic and Health Surveys (DHS) in 27 developing countries found that 67
per cent of women who gave birth within the previous year had an unmet need for
family planning [7]. Although unmet need for family
planning during the postpartum period is widespread among all women, evidence
from recent studies has shown that substantial proportions of women living with
HIV also have an unmet need. Studies in Zambia and Kenya found that 39 per cent
and 65 per cent of postpartum women living with HIV reported that they were not
using any contraceptive method with their regular sexual partner [8].
To prevent
vertical transmission of HIV, there is evidence that even if counseling and
information on family planning is available within programmes for the prevention
of mother-to-child transmission of HIV (PMTCT), this does not necessarily
translate into the initiation of contraception [9].
Evidence
has shown that providing a continuum of care from antenatal, delivery,
postnatal services and beyond results in improved maternal and neonatal health
outcomes [10-12].
For example, in Swaziland, integration of PMTCT into postnatal care led
to considerable improvements in follow-up visits during the first three days
postpartum, a significant increase in the proportion of postpartum women and
their partners who got tested for HIV, an increase in the proportion of women
and infants who received HIV treatment and care, and significant improvements
in the proportion of mothers practicing exclusive breastfeeding [11].
However,
there is still a paucity of evidence from southern and eastern Africa (where
HIV prevalence is highest) focused on measuring the benefits of integrated HIV
and sexual and reproductive health services, particularly, postnatal care
services.
As part of
the Integra Initiative, our study in Kenya has contributed to filling this gap
and aimed to build the evidence base by assessing the effect of integrating HIV
and postnatal care services on the uptake of provider-initiated HIV testing and
counseling and family planning services among women attending postnatal care in
public health facilities. Preliminary results indicate that an integrated
delivery approach of postnatal services is beneficial in increasing the uptake
of HIV testing and family planning services among postpartum women, including
the uptake of long-term family planning methods. However, there are important
gaps in the uptake of these services based on facility-type and
socio-demographic characteristics. This has important implications in
addressing the sexual and reproductive health and HIV needs of women, including
prevention of unintended pregnancies.
References listed in the full issue of the IPPF HIV Update newsletter: http://ippf.org/resource/HIV-Update-April
